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At the last Essentials of Correctional Medicine conference, Dr. Marc Stern gave a thought-provoking lecture about the proper use of nurses in the correctional setting. I have to admit that his talk was a bit controversial; some of the nurses in attendance were uncomfortable and even a little offended. But whether you like Dr. Stern’s talk or not, his thoughts deserve some consideration.

The main thrust of his talk was to compare how nurses are used outside of corrections—the community standard as it were–as opposed to how nurses are used inside jails and prisons. There are quite a few differences. Why is this so? And if nurses are used inside of correctional facilities differently than the community standard, is this proper?

Dr. Stern brought up two distinct differences between how nurses are used in the community and how they tend to be used in corrections: Acute Care and Chronic Care. I am going to discuss the Acute Care issue today and the Chronic Care issue in my next post.

The Nursing Role in Acute Care Clinics–Community vs. Corrections

The single major difference between how nurses are used in the community and how they are used inside correctional facilities is this: in the community, nurses do not run acute care clinics–ever. Nurses in the community do not diagnose or prescribe treatment. It does not matter whether you go to your doctor’s office or a hospital emergency department or a “Doc-in-the-Box” urgent care clinic or even one of those mini-clinics you find in grocery stores nowadays. In each case, you will be seen by a medical practitioner of some sort; whether a doctor, a physician assistant or a nurse practitioner. Nurses will be there, but in the role of assisting the practitioner. It just will not happen in the community that a patient will be seen only by a nurse—no practitioner in sight—who does an examination, makes a diagnosis like, “You have bronchitis,” and hands out a prescription.

On the other hand, acute “sick call” clinics in correctional facilities are commonly run only by nurses. These nursing clinics tend to be of three main types:

Triage clinics. In this type of clinic, a nurse sees every patient who puts in a medical request and schedules them to see a practitioner depending on the urgency of the complaint. For example, a patient complaining of abdominal pain might be scheduled for the very next medical clinic whereas a patient complaining of dandruff might be scheduled a week out. The Triage nurse could also have the on-call practitioner come in urgently to evaluate a patient with, say, chest pain or decide to send that patient to the ER. However, in this model, nurses never diagnose or prescribe treatment.

OTC clinics. “OTC” stands for “Over-the-Counter” medications that do not require a doctor’s prescription. In this type of nurse clinic, a nurse again sees every patient with a medical request and schedules medical clinic appointments, but also is authorized to dispense over-the-counter medications for common minor complaints. For example, a patient with abdominal pain still would be scheduled in to medical clinic, but a patient with athlete’s foot might be given OTC clotrimazole cream by the nurse without the patient ever seeing a practitioner. Some facilities have quite detailed protocols to guide nurses in this endeavor, but not all.

Full Service Nurse Clinics. In some correctional facilities, nurses take care of almost all sick call patients. The nurse will still schedule complicated patients to see the practitioner, but will take care of other, simpler, problems even if these require a prescription medication. If a nurse thinks that a patient needs a medication requiring a doctor’s prescription, he/she usually will call the on-call practitioner for authorization. An example would be a female inmate thought to have a Urinary Tract Infection. The nurse would call the practitioner for orders, say an antibiotic, and then administer it. Sometimes, this patient will be seen by the practitioner in a subsequent clinic, but not always.

As Dr. Stern pointed out in his talk, it is clear that this system of using nurses in jails and prisons is very different from the “community standard.” Dr. Stern also pointed out that in many correctional facilities, the nurse performing these tasks is not an RN, but an LPN or even a “Correctional Medical Technician” with even less formal medical training than an LPN. The concern is that by running acute care clinics, which involves making diagnoses and prescribing treatment, nurses may be exceeding their scope of practice.

Why Are the Two Systems Different?

Personally, I can easily see how this system of nursing duties evolved within corrections. Community urgent care clinics have a practitioner in attendance at all times. These clinics are never staffed with nurses only. But jails and prisons are not that way. Consider very small jails, for example, where the doctor’s sick call clinic may only be held once a week. Someone, then, has to evaluate inmate medical requests to decide if the inmate can safely wait until the next scheduled clinic, which may be days away. You certainly don’t want the inmate with appendicitis to wait a week to see the doctor! And the jail nurse is certainly a better choice to do this evaluation than a detention deputy!

But what if the inmate complaint is so simple that it only requires an Over-the-Counter medication? Say heartburn? The inmate can certainly wait until clinic but why can’t the nurse just give out some OTC ranitidine? Or foot fungus cream for athlete’s foot? Is it even ethical to make the inmate suffer until clinic for such a simple problem? On the outside, the inmate would not even have to go to medical. They could just go to the store and buy ranitidine. Can’t a nurse just give the patient some OTC ranitidine?

Other simple inmate complaints can be just as easily resolved with prescription medications. Take the young healthy woman who has the classic symptoms of a urinary tract infection: dysuria, urgency and frequency. Can’t we get the antibiotics started before the doctor’s clinic? Do we make her wait? And what about other, more serious, medical problems like alcohol withdrawal that absolutely should not wait until the next sick call. Librium must be started now, whether there is a doctor on site or not.

But then, it is but a short, dangerous step to the next level: By the time the doctor comes in for clinic, the woman with the UTI is cured! The alcohol withdrawal patient is doing well! The patient with heartburn has no complaint! Isn’t it just a waste of the doctor’s valuable time to see these asymptomatic patients?

In the end, you have the scenario where a nurse has made a diagnosis and perhaps prescribed treatment without a practitioner ever having seen the patient and maybe even without ever having been contacted! Somewhere along that continuum is a fine line that, when crossed, means that nurses are diagnosing and treating beyond their scope of practice.

In prisons, where a practitioner may be present in the facility every single day, it may be possible to run acute care clinics as they are done on the community. However, it also may not be feasible. Since I don’t practice in a prison setting, I will leave the discussion of the proper role of nursing clinics in prison to my prison based colleagues! Please comment below!

However, in jails, it is simply not possible to run acute care clinics like the community standard. No 50-bed jail can afford to have a doctor show up for clinic every day. Even large jails don’t typically have practitioners on site every day. There has to be some sort of partnership with nurses to triage medical requests and to take care of simple problems. However, jails should take care not to cross the line where nurses exceed their scope of practice!

The following reflects my personal opinions on the subject:

Nurses should have a protocol or guideline to follow when they evaluate simple complaints that can be treated with OTC medications. Patients with complaints like “I have athlete’s foot and need cream for it” or “I have heartburn–can I have some Zantac?” do not necessarily need to be seen by a doctor since they do not need to see a doctor on the outside to obtain these items. But even these simple complaints can be fraught with some danger—like when the guy with “heartburn” is really having a heart attack. Nurses should have written guidelines that indicate when OTC remedies are appropriate and what “Red Flags” indicate a referral to clinic. If nurses have such guidelines, they are not diagnosing and treating independently; they are instead assisting patient to obtain appropriate OTC medications.

Why make inmates see a nurse to get OTC medications in the first place? People outside of jail don’t have to go to a clinic to get Zantac or foot fungus cream or whatever. They just go to the store and buy them! So why do we make them do it in jails? It is a waste of both the nurse’s time and the inmate’s time. Put appropriate OTC medications on the commissary (see You Need a Medical Commissary in Your Facility! and Obstacles to a Medical Commissary Program.

If a nurse thinks a patient needs an urgent prescription drug before the next medical clinic, the on-call practitioner must be called for an order! Nurses should not start prescription medications based on protocols alone. That is not done in the community; it should not be done in correctional facilities. For example, if a nurse sees a MRSA lesion and wants to start antibiotics before the next clinic, he must call for an order. Does an alcoholic need to begin therapy for withdrawal tremors? Call. If these calls are not made, then the nurse has diagnosed and prescribed treatment independently, outside of the scope of practice. The only exception to this rule is emergency treatment, like epinephrine for anaphylaxis.

Every patient who receives a prescription medication should be seen by a practitioner! I don’t mind authorizing antibiotics over the weekend for a woman with a UTI. But I then am obligated to see her, however briefly, in my next medical clinic. It doesn’t matter if she is better—that just means that the clinic visit will be brief. But if I prescribed the medication, I need to document a history and an examination in her chart. If I don’t, the nurse again diagnosed and prescribed beyond her scope of practice, albeit with my “rubber stamp.” Interestingly, here in Idaho, the Board of Medicine recently condemned the practice of prescribing medication without examining the patient. The Board was specifically addressing situations like when a family member or friend calls and says, “I have a sore throat. Will you call something in?” But the principle applies to this situation in corrections, as well. If I prescribe something, I need to see the patient and document a history and physical.

As always, I have expressed my own opinion here. Feel free to disagree. I might be wrong! But if you do disagree, please comment and explain why!

Next Post: Chronic Care Clinics in Corrections vs. the Community!

In the Essentials of Correctional Medicine Conference, Dr. Stern’s lecture on nursing roles raised some eyebrows. What is your opinion on nursing roles in corrections?

Everyone who works in corrections is familiar with inmates wanting medical authorization to wear their own shoes. A typical case would go something like this: “I have chronic back pain and walking on these hard concrete floors makes it worse. Will you authorize me to wear my own shoes? You did last time I was in here and it really helped.”

We need to keep in mind, however, that allowing an inmate to wear his own shoes gives that inmate secondary gain. Shoes from home are, indeed, more comfortable than the typical jail sandals. Also, any inmate who is granted a special privilege, like wearing his own comfy shoes, gains status among the other inmates. When we approve inappropriate requests for “own shoes,” we are bestowing prestige upon that inmate. And we are denying that prestige to those who we refuse. The unfairness of this is not lost on inmates. Finally, “own shoes” are occasionally used to smuggle contraband into the facility. I remember one pair that had an ingenious hollow space carved out of the sole that was not easy to find on a typical security examination. If you routinely grant requests for “own shoes,” you will inevitably get burned in this way. Continue reading →

When I was an undergraduate, before I switched to pre-med, I was an economics major. Maybe because of that training, when I look at jail medical practices, I tend to look at all of the costs of medical practice, not just the monetary costs. For example, the total cost of providing a medication to a patient in the jail includes the cost of the medication (of course), but it also includes the cost of the various people, like nurses, pharmacists, deputies and practitioners, who spend time creating the prescription. Thinking of costs in this way can change our perspective of what something “costs.”

Consider the case of the man with heartburn. We’ll call him “Jeffrey.” He doesn’t know it, but he is about to go to jail. Before Jeffrey goes to jail, if he wants to purchase something like ranitidine (Zantac) for his heartburn, he would go to a store and buy it. He doesn’t need to see a medical professional. He doesn’t need a prescription. In most places, he doesn’t even need to wait—convenience stores sell ranitidine 24/7. The monetary price Jeffrey will pay for 50 tablets of ranitidine at the store is around $7.00. The cost in terms of time is how long it takes him to run to the store. The total cost in time to the store to provide the ranitidine to Jeffrey is 30 seconds—how long it took the store clerk to ring up the sale.

Now think of the same guy in jail. Jeffrey still has heartburn. Let’s say he still has money—now in his commissary account. He is still willing to buy ranitidine. But ranitidine is not on the jail commissary list. He can buy Ramen noodles or a Snickers bar, but not ranitidine. In order to get ranitidine, he has to put in a “Request for Medical Care” form. What happens now varies from jail to jail and prison to prison. I am going to present a typical jail scenario.

The act of requesting non-emergent medical care costs Jeffrey $10.00. The form is then triaged by a nurse and Jeffrey is scheduled to see a practitioner. Since the clinics are crowded, the appointment is made for five days hence. In the meantime, he continues to have heartburn. On the scheduled day, he comes to the medical clinic. He waits, say, an hour in the waiting area. He then has vitals taken by a nurse. The practitioner, unsurprisingly, orders a prescription of ranitidine from the pharmacy for Jeffrey. The order is sent to the pharmacy and is delivered the next day. It is paid for from the jail medical budget.

About

Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of emergency medicine practice experience before moving full time into his “true calling” of Correctional Medicine. He is the Medical Director of Badger Medical, which provides medical services to several jails and juvenile facilities in Idaho. Dr. Keller is available for consultation on any aspect of Correctional Medicine, including legal cases, program development, and system analysis.

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